WIMJOURNAL, Volume No. 3, Issue No.

1, 2016 pISSN 2349-2910

eISSN 2395-0684

REVIEW

Reverse transcriptase and protease inhibitor resistant mutations in art

treatment nave and treated HIV-1 infected children in India
A Short Review
Dinesh Bure,
Department of Biochemistry, All India Institute of Medical Sciences, New Delhi

Abstract:
Introduction of first line and second
line antiretroviral therapy has dramatically
improved the quality of life and survival of
the HIV-1 infected individuals. Extension of
this therapy in children has similar effect.
However the emergence of drug selected
resistance has hampered the response to the
therapy. A database of prevalence of drug
resistance mutations in the Indian children
both ART nave and treated will help in
deciding the appropriate regimen for the
individual patient as well as formulating the
policies regarding the composition of drugs
included in the fixed dose combinations and
its periodic review by analysis of the
information that is made available from time
to time. This will enable us to utilize our
limited resources in most prudent way.
Keywords:
Drug Resistance, Mutations, Reverse
transcriptase, and Protease.
Introduction:
According to UNAIDS Global AIDS
Update 2016(1) around 36.7 million people
(all ages) are living with HIV, out of which
2.1 million are new HIV infections. An
estimated 1.8 million Children are infected
with HIV worldwide. National AIDS
Control Organisation (NACO) reports that
around 21.17 lakh people are infected with
HIV in India. Out of these 6.54% are
children (<15 years)(2).
Children can have an infection with
HIV via mother to child transmission,
infected blood and blood products and
through sexual assault. Most of the
paediatric HIV infections are due to mother
to child transmission. The infection can be
transmitted from mother to her child during
pregnancy, labour, delivery or breastfeeding.
Most commonly it occurs during peripartum
period(3).
Introduction of Antiretroviral
Therapy (ART) has dramatically increased
survival and quality of life of a patient
having HIV(4). ART has been effective in
both reducing viral load as well as in

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WIMJOURNAL, Volume No. 3, Issue No. 1, 2016
increasing the CD4 counts of HIV infected
individual. However the long term response
to ART is hampered by the emergence of
drug resistant mutations in the
(5)
genome . The viral genome replication by
viral reverse transcriptase enzyme is highly
error prone leading to genetic diversity of
the viral pool. Individual treated with ART
puts selection pressure on virus with the
emergence of drug resistant strains over a
period of time. Children can acquire drug
resistant strain from mother via vertical
transmission(6). Single dose Nevirapine used
for prevention of mother to
transmission has also been demonstrated to
be responsible for Non Nucleoside Reverse
Transcriptase Inhibitor (NNRTI)
mutations(7).
As ART is being given to more and
more individuals and with the emergence of
drug resistant mutations for the first line
therapy it is imperative to have knowledge
of prevalence of mutations a population
harbours so that the treatment can be
customized accordingly.
HIV-1 Reverse Transcriptase Mutations:
The study conducted
(8)
Soundararajan et al. in 48 drug nave south
Indian children showed no significant drug
resistant mutation in reverse transcriptase
gene. However more than half of the
sequences had important amino
substitutions in codons 35, 36, 39, 48, 60,
121,135, 162, 173,177, 200, 207, 211, 214,
Walawalkar International Medical Journal
Bure D.G.
and 245. In about 30% of sequences
Threonine was substituted by Glutamic Acid
at position 39 and 45% sequences had
viral Aspartic acid in position 39.
An analysis of genotyping of 12
virological failure ART treated Children in
St. Johns, Bangalore reveal that 11 out of 12
had clinically relevant drug associated
mutation in the reverse transcriptase gene(9).
The most frequent Nucleoside Reverse
Transcriptase Inhibitor (NRTI) mutation was
M184V associated with resistance to
Lamivudine, Abacavir and Emtricitabine.
child Other common NRTI mutations were M41L
and T214Y/F/I. Both these mutations confer
intermediate level cross resistance to
drug Tenofovir. K103N/R, Y181C and G190A
were the most frequent NNRTI mutations
with associated resistance to Nevirapine,
Efavirine and intermediate to high cross
resistance to Etravirine.
A clinical brief by Shah et al.(10)
reported two cases of ART treated children
in B.J Wadia Hospital, showing both
TAMS-1 (M41L, T215Y/F, L210W) and
TAMS-2 (D67N) mutations. These
mutations are cross resistant to all NRTIs
by and are selected for by Stavudine or
Zidovudine.
A study conducted in Pune, India
reported drug resistant mutation for NNRTI
in 7.4% ART nave children(11). They
acid identify A98G and K103N mutation in the
two separate sequences. A98G mutation
confers low level resistance to NNRTIs and
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WIMJOURNAL, Volume No. 3, Issue No. 1, 2016
K103N confer high level resistance to
Efavirine and Nevirapine.
A genotyping analysis of ART nave
and treated children in AIIMS, New Delhi
reveal that drug resistant RT mutation was
present in 30% of ART nave and 36% of
ART treated children respectively(12). RT
mutations conferring resistance to NRTI
drugs were identified at positions
65,67,74,77,151,184,215,219. Mutations in
the RT gene that confer resistance to NNRTI
drugs were detected at amino acid positions
101, 106, 179, 190, and 227. One ART nave
patient had both K101E and G190A
mutations which confer high level resistance
to Nevirapine and Efavirine.
NNRTI mutations after
administration of single dose Nevirapine in
both mother and child has been reported
(13)
previously . In India a feasibility study
conducted at National AIDS Research
Institute (NARI), Pune had observed that
10.5% of children had low levels mutation
for NNRTI after 48 hours of administration
of single dose Nevirapine and 46.15% of
children had high level of NNRTI resistant
mutation after 2 months of single dose
Nevirapine prophylaxis(7). Although this
study failed to find K103N mutation, one of
the common NNRTI mutation, presence of
low to high level resistant mutation even
after single dose of Nevirapine is highly
significant.
As it is a common observation that
the resistance to Nevirapine develops after
Walawalkar International Medical Journal
Bure D.G.
single dose or after interruption of therapy,
Sehgal et al. investigated the K103N
mutation which confer resistance to
Nevirapine in 25 children in which 6 were
ART nave and rest 19 were on Nevirapine
containing fixed dose combination therapy.
K103N mutation was found in 56% of
children including two drug nave
individuals(14).
The presence of Reverse
Transcriptase mutations in ART nave
children should raise a general concern. This
necessitates the genotyping of individual
case before starting ART therapy. Same is
applicable in a patient where change in
therapy regimen or individual drug is being
considered.
HIV-1 Protease Mutations:
With the introduction of 1st line
ART, over a period of time treatment failure
appears in score of individuals. Who are
then shifted to 2nd line ART containing
protease inhibitors. Baseline drug resistant
mutation profile of protease inhibitors is
largely unknown in the population. Resistant
strain may also be vertically transmitted
from mother to child if mother is receiving
protease based regimen. Due to recent
introduction of 2nd line ART very few
studies have been conducted to look for
protease inhibitor resistant mutations.
Soundararajan et al. found no major
mutation in the protease gene of 48 ART
nave children(8). However they observe that
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more than half of the sequences had
polymorphism at position 12,19,41,89 and
93. Frequent substitutions were seen at
positions 15, 36, 63 and 69.
Shet et al. after doing genotyping of
80 children on first line of ART couldnt
find any protease resistant mutation in any of
the sample although they had detected
significant mutations for reverse
transcriptase gene(9).
Protease inhibitors selected major
mutations has been observed by Toor et al.
in a study conducted at PGIMER,
Chandigarh. Both major and minor
mutations were seen in patients with first
line ART treatment failure(15). One patient
had L33F and I47T major mutation. L33F is
selected by each of the Protease Inhibitors
except Atazanavir, Indinavir and Saquinavir.
In combination with other Protease Inhibitor
resistant mutations L33F reduce the
susceptibility to each of the Protease
Inhibitors. I74V It associated with reduced
susceptibility to each of the Protease
Inhibitors except Saquinavir and Atazanavir.
The same patient also had minor mutations
M46G and G48E. Other minor mutations
observed were L10I and T74S in one
individual each.
A study conducted at AFMC, Pune
involving 27 ART nave children observe no
major mutations in the protease gene. But 3
individual had single minor mutations
(11)
namely L10I, A71T and T74S . L10I is an
accessory mutation, which either reduce
Walawalkar International Medical Journal
Bure D.G.
Protease Inhibitor susceptibility or increase
the replication of viruses containing Protease
Inhibitor resistance mutations. A71T is a
common accessory polymorphic mutation
that increase replication and/or reduce
Protease Inhibitor susceptibility in viruses.
Another accessory mutation found was T74S
which is polymorphic in non B-subtype
viruses.
Shah et al. have reported two cases
of first line treatment failure children having
both major and minor mutations for the
protease inhibitors(10). The first case had
major mutations at position 46 and 54 and
minor mutations at positions 10,20,36,63.
The genotyping points towards the high
resistance to Nevirapine with possible
resistance to Amprenavir. The second
patient had major mutation D30N and minor
mutations at positions
13,17,19,20,35,36,37,41,45,57,63,64,69,74
and 93 conferring high resistance to
Nevirapine possible resistance to Ritonavir
boosted Atazanavir (ATV/r).
The AIIMS, New Delhi study
detected five children having single minor
mutation for the protease gene in codon 10,
76 and 84(12). Out of these five 2 children
were on first line drugs and rest were ART
nave. The minor mutations were L10I/V,
L76T and I84R/T. L10I/V are associated
with resistance to most Protease Inhibitors
when present with other mutations. L76T
and I84T are highly unusual mutations at
these positions.
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With the introduction of second line
therapy containing protease inhibitors for
(16)
first line treatment failure children
advisable to check for the Protease Inhibitor
selected mutations before starting
treatment.
HIV-1 Subtypes:
Subtype C is the most common
subtype in India in adults as well as in
(17)
paediatric age group . Most of the
genotyping studies done in India
paediatric age group reveals HIV-1 subtype
C. However other subtypes have also started
emerging in Indian paediatric population.
Toor et al. reported two first line treatment
failure children of subtype B harbouring
polymorphism at different positions for
protease gene(15). Kumar et al. in their study
had two protease isolate align with subtype
A1 and one RT isolate align with subtype
A1(11). However the significant observation
of subtype diversity came from study at
AIIMS, New Delhi. The authors found that
30% of Reverse Transcriptase sequences are
clustering with subtype B and 36% of
protease gene sequences are aligning with
subtype B(12). they also had one ART nave
individual whose sequence align
subtype A. All these observations point
towards the emergence of HIV-1 subtype
diversity in Indian paediatric population.
Walawalkar International Medical Journal
Bure D.G.
Circulating Recombinant Forms (CRFs):
Till date no study has been able to
, it is detect circulating recombinant form of HIV
in Indian paediatric population.
the
Future:
As more number of first line
treatment failure patients are emerging,
genotyping of individual patient helps in
customizing therapy for that individual and
avoiding the drugs mutations against which
in are already present. The importance of
population data of drug resistant mutations
cannot be more emphasized. It will help in
formulating the combination of drugs to be
included in the regimen and also fixing the
recommended dosage. To be enable to do
this more drug resistance mutation studies
needed to be conducted and more classes of
drugs required to be included in the research
investigation.
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Address for Correspondence:

Dr. Dinesh Bure,
Department of Biochemistry, All India Institute of Medical Sciences, New Delhi
Email ID: dinesh2141986@gmail.com

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